TCD
Billing, Coding, Reimbursement
Charles H. Tegeler, MD
McKinney-Avant Professor of Neurology
Director, Comprehensive Stroke Center
Director, Ward A. Riley Ultrasound Center
Medical Director, Neurosonology Lab
WFUSM
Billing, Coding, Reimbursement
 Review
CPT codes for TCD
 Definition of complete and limited
 Approach to ICD coding
 Keys to reimbursement
 Updates on TCD accreditation
 Questions
Reimbursement
Will you get paid?
Neurosonology CPT Codes
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93875 Physiological testing extracranial arteries,
complete bilateral study
93880 Duplex scan extracranial arteries, complete
bilateral study
93882 Limited or unilateral duplex
93886 TCD intracranial, complete study
93888 TCD intracranial limited study
93890 Vasoreactivity study
93892 Embolus Detection without bubbles
93893 Embolus Detection with bubbles
New CPT Codes for TCD
3 new CPT codes approved for TCD
 Took effect 1/1/05
 Mandated a new definition of complete
and limited TCD examination
 New codes for cerebrovascular reactivity
(93890), embolus detection without
bubbles (93892), embolus detection
with bubbles (93893)
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New CPT Codes for TCD
Complete / Limited
Complete TCD: Includes attempted
ultrasound evaluation of 3
circulations; the right and left
anterior circulation by the temporal
acoustic window and the posterior
circulation including the vertebral
and basilar arteries
 Anything less is limited TCD
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Practical Laboratory Issues
- NC Medicare Policy
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It is the responsibility of the provider to ensure the
medical necessity of procedures and to maintain a
record for possible audit. Clinicians billing
Medicare are encouraged to obtain additional
information from referring providers and/or
patients to determine the medical necessity of
studies. Referring physicians are required to
provide appropriate diagnostic information to the
performing technologist/physician
Neurosonology ICD Codes
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ICD coding is crucial
ICD Codes are diagnosis codes that may
support medical necessity for CPT code
Acceptable codes vary between carriers
Listed in LMRP/LCD for Medicare Carrier
Must learn/know what is acceptable, and
know denial and appeal policies
Algorithms can be helpful
Neurosonology ICD Codes
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Code based on known clinical diagnosis
(i.e. stroke)
If no clear Diagnosis, list ICD code based
on symptom/sign
If no clue, contact referring Dr/office
Can code based on apparent indication,
whether test is abnormal or not!
Make sure codes are transmitted to
billing office, and included in
submission; plug the holes in the bucket
Acceptable ICD-9 Codes for
TCD per NC Medicare
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282.5
282.6-282.69
348.8
430
433.00- 433.01
433.10- 433.11
433.20- 433.21
434.00- 434.91
434.01, 434.11
435.9
436
447.1
747.81
Sickle cell trait
Sickle cell anemia
Other condition of brain… brain death
SAH
Occlusion/stenosis basilar artery (without/with stroke)
Occlusion/stenosis carotid artery (without/with stroke)
Occlusion/stenosis vert. Artery (without/with stroke)
Occlusion of cerebral arteries
Cerebral thrombosis, cardioembolic stroke
Unspecified transient cerebral ischemia (TIA)
Acute, ill-defined cerebrovascular disease
Stricture of intracranial artery
Anomalies of cerebrovascular system (AVM)
ICD/CPT Codes and LMRP/LCD
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Medicare Local Medical Review
Policies/Local Carrier Directives (LMRP/LCD)
address and update tests (CPT) and
indications (ICD)
 Current LMRP/LCD’s available on line; check
your local/regional carrier, i.e. NC Medicare
(CIGNA)
 Influences Medicaid and other payers, but
they may be different
CPT/ICD Codes
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Frustrating but mandatory
Day to day is local issue, but must be
aware and proactive for national issues
LMRP/LCD Policies vary by state/carrier
Know and use your society
representation (AIUM, ASN, ACR, etc)
Don’t just gripe; Get Involved!
Carrier Advisory Committee
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CAC for each Medicare regional carrier
Many reimbursement problems result
from lack of knowledge, understanding of
issues
CAC Advises Medical Director regarding
LMRP/LCD
CAC made up of reps from State Medical
Societies and others
Know your CAC specialty rep, or get
involved yourself
Reimbursement
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Amount varies widely by region
 Global fee
 Technical and Professional
 Inpatient (DRG)
 Outpatient considerations
 Impact of DRA – inclusion of TCD with
imaging modalities –trying to change
Keys to Reimbursement
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Correct coding of procedure done
Correct, reimbursable diagnosis code
Must list indication and ICD code in the
report itself
Be familiar with your local Medicare
carrier medical review policy
Know local policies for denials and
appeals policy
Medical Director / Medical Staff
 Required
Experience and Training
– Formal training program
– Informal training
– Established practice
– RPVI credential or
ASN neurosonology certificate
2007 Revisions Intracranial
Testing
Transcranial Doppler (TCD) or transcranial
duplex must be provided as instrumentation
 The laboratory protocol must define the extent of
power reduction to be used for transorbital
examinations. For patient safety, the output power
must not exceed 10% of maximum emitted power
or 17 mW per cm2 or equivalent measurements
 30 correlation studies for TCD (now consistent
with other areas of testing)
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Now
available –
ICAVL
Online
Application
through IAC
Physician Certification
No uniform mechanism for
physician certification in neuroultrasound
 Increasingly important for hospital
privileges
 AAN approved neuroimaging
training guidelines for neurology
residencies
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– Neurology 1997; 49:1738-40
ASN Certification Exam
Tool for Physicians to show
additional training/expertise
 Important if MD to also be Tech
Director
 Computerized exam:
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Principles and Physics
Cerebrovascular extracranial
Cerebrovascular intracranial
Pediatric neurosonology (not active)
Physician Certification
Eligibility for ASN Exam
Board certified or eligible; Valid medical
license
 Completed residency that meets guidelines
for adequate training in neurosonology
 Verification of at least 40 hours of Category
I CME in neurosonology in past 3 yrs, and
of perf/interpretation of at least 100 studies
of each type (carotid, TCD, pediatric) under
supervision
 Details and membership info at asnweb.org
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Neursonology Practice
Certifications
ASN physician exam helps for privileges,
ICAVL accreditation (training for Medical
Director/Staff; if must serve as Technical
Director as well)
 ARDMS offers RPVI exam for physicians
 Sonographer certification lacks
mechanism for cerebrovascular testing
 ASN working to create sonographer
neurovascular certification exam
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Key Websites
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American Society of Neuroimaging: www.asnweb.org
Neurosonology Research Group of the World
Federation of Neurology: www.nsrg.org.tw
Intersocietal Commission of the Accreditation of
Vascular Laboratories: www.icavl.org
American Institute of Ultrasound in Medicine:
www.aium.org
American Registry of Diagnostic Medical Sonography:
www.ardms.org
TCD
Billing, Coding, Reimbursement
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Questions?